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REGIONAL ANESTHESIA AND PAIN MEDICINE

The Efficacy of Hemodynamic and T wave Criteria for Detecting Intravascular Injection of Epinephrine Test Doses in Anesthetized Adults: A Dose-Response Study

Department of Anesthesia, Akita University School of Medicine, Akita-ken, Japan

Address correspondence and reprint requests to Makoto Tanaka, MD, Department of Anesthesia, Akita University School of Medicine, Hondo 1-1-1, Akita-shi, Akita-ken 010-8543, Japan. Address e-mail to mtanaka{at}med.akita-u.ac.jp

Recent studies have shown that an epidural test dose containing 15 µg of epinephrine has a sensitivity and specificity of 100% for detecting intravascular injection based on the systolic blood pressure (SBP) (positive if 15-mm Hg increase) and the T wave criteria (positive if 0.1 mV and 25% decrease in amplitude), whereas the modified heart rate (HR) criterion (positive if 10-bpm increase) produced uncertain results in sevoflurane-anesthetized adults. Because a fractional dose of the test dose may be injected intravascularly in actual clinical situations, we designed this study to determine, in a dose-related manner, the efficacy and minimum effective dose of epinephrine based on those hemodynamic and the T wave criteria. Eighty healthy adult patients were randomly assigned to one of four groups according to a simulated IV test dose under 2% end-tidal sevoflurane and nitrous oxide anesthesia after endotracheal intubation (n = 20 each). The saline group received 3 mL of normal saline IV; the epinephrine-15 group received 3 mL of 1.5% lidocaine containing 15 µg of epinephrine (1); and the epinephrine-10 and -5 groups received 2 and 1 mL of the test dose of the identical components, respectively. HR, SBP, and lead II of the electrocardiograph were recorded continuously for 5 min after the IV injection of the study drug. Sensitivities and specificities of 100% were obtained based on the HR and the SBP criteria only if 15 µg of epinephrine was injected IV, whereas sensitivities and specificities of 100% were obtained based on both T wave criteria after 15 and 10 µg of epinephrine was injected IV. Two blinded observers were able to detect all T wave changes in patients who received 15, 10, and 5 µg of epinephrine IV, resulting in 100% efficacy (P < 0.05 versus HR and SBP criteria). We conclude that minimum effective epinephrine doses for detecting accidental intravascular injection are 15 µg on the HR and the SBP criteria, and 10 µg on both T wave criteria, and that observing T wave changes may detect even smaller (5 µg) doses of epinephrine injected IV in adult patients anesthetized with sevoflurane and nitrous oxide.

Implications: To determine whether an epidural catheter is in a blood vessel, an epidural test dose containing 15 µg of epinephrine is used. We found that a decrease in T wave amplitude appears to be more sensitive than heart rate and systolic blood pressure change for detecting accidental intravascular injection of a small dose of epinephrine-containing test dose in sevoflurane-anesthetized patients.

This article has been cited by other articles:

				J. Guay The epidural test dose: a review. Anesth. Analg., March 1, 2006; 102(3): 921 - 929. [Abstract] [Full Text] [PDF]

				M. Tanaka and T. Nishikawa Does the Choice of Electrocardiography Lead Affect the Efficacy of the T-Wave Criterion for Detecting Intravascular Injection of an Epinephrine Test Dose? Anesth. Analg., November 1, 2002; 95(5): 1408 - 1411. [Abstract] [Full Text] [PDF]

				S. Takahashi, M. Tanaka, and H. Toyooka The Efficacy of Hemodynamic and T-Wave Criteria for Detecting Intravascular Injection of Epinephrine Test Dose in Propofol-Anesthetized Adults Anesth. Analg., March 1, 2002; 94(3): 717 - 722. [Abstract] [Full Text] [PDF]

				M. Tanaka, M. Sato, T. Kimura, and T. Nishikawa The Efficacy of Simulated Intravascular Test Dose in Sedated Patients Anesth. Analg., December 1, 2001; 93(6): 1612 - 1617. [Abstract] [Full Text] [PDF]

				M. Tanaka and T. Nishikawa T-Wave Amplitude as an Indicator for Detecting Intravascular Injection of Epinephrine Test Dose in Awake and Anesthetized Elderly Patients Anesth. Analg., November 1, 2001; 93(5): 1332 - 1337. [Abstract] [Full Text] [PDF]

Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999